Paediatric respiratory Flashcards
Explain the different age groups affected by bronchiolitis, viral induced wheeze and asthma
- > Bronchiolitis : 6mns usually (less than <1 yr)
- > Viral induced wheeze : <3 years
- > Asthma : >3 years
What is the most common viral cause of bronchiolitis ?
-RSV -> respiratory syncytial virus
What can be given to high risk babies to protect against bronchiolitis
- Palivizumab -> monoclonal antibody targeting RSV.
- Given as a monthly IM injection
How does bronchiolitis present ?
- Wheeze and crackles
- Coryzal symptoms
- Tachypnoea
- Dyspnoea
- Dry cough
- Poor feeding
- Mild fever
- Apnoeas
- Signs of respiratory distress
what would suggest a diagnosis of pneumonia over bronchiolitis ?
- High fever (>39 degrees)
- Persistently focal crackles
What 6 factors would suggest admission to hospital for bronchiolitis ?
- Oxygen at 92% or below
- RR >70
- Moderate to severe resp distress
- 50-75% less of nomral milk intake
- Apnoea
- Clinical dehydration
How is bronchiolitis managed in hospital ?
Supportive
What is the stepwise approach to ventilation support in bronchiolitis ?
- High-flow humidified oxygen via tight nasal cannula
- Continuous positive airway pressure
- Intubation and ventilation
Define croup
-Acute, infective, URTI causing oedema of the larynx
What age group does croup typically affect?
-6mnths to 2yrs
What is the most common cause of croup?
-Parainfluenzae
Give 5 symptoms of croup
- ‘Barking’ cough
- Stridor
- Low grade fever
- Hoarse voice
- Increased work of breathing
How is croup managed if more than supportive care is needed ?
- Oral dexamethasone (single dose of 0.15mg/kg)
What is determined as mild croup
- Occasional barking cough
- No audible stridor at rest
- No or mild suprasternal or intercostal recession
- Child is happy and prepared to eat, drink and play
What is defined as moderate croup
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress and agitation
- Child can be placated and is interest in its surroundings
What is defined as severe croup
- Frequent barking cough
- Prominent inspiratory stridor
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness
- Tachycardia and hypoxaemia
Give the stepwise management of croup
- Oral dex
- Oxygen
- Nebulised budenoside
- Nebulised adrenaline
- Intubation and ventilation
Give the normal RR based on age
- <1 yr : 30-40
- 1-2 yrs : 25-35
- 2-5 yrs : 25-30
- 5-12 yrs : 20-25
- > 12 yrs : 15-20
Give 8 signs of resp distress
- Raised resp rate
- Use of accessory muscles
- Intercostal and subcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tug
- Cyanosis
- Abnormal airway noises : wheeze, stridor, grunting
What is whopping cough and what causes it ?
- URTI
- Bordetella pertussis (gram neg)
How does whooping cough present ?
- 1 wk Preceding coryza
- 3- 6 wks severe paroxysmal coughing fits with large inspiratory whoop.
- Possible apnoea presentation
How is pertussis diagnosed ?
- Nasal swab with PCR testing or bacterial culture within 2 to 3 wks of symptoms
- If cough present for >2 wks : anti-pertussis toxin immunoglobulin G on oral fluid aged 5-16 and blood if >17
How is whooping cough managed ?
- <6 mnths. = admit
- Oral macrolide if within 21 days of cough (erythromycin)
- Household prophylaxis
- School exlusion : 48 hrs after starting Abx
What is a key complication of whooping cough ?
-Bronchiectasis
What causes laryngomalacia
- Congenital short and soft aryepiglottic folds making the epiglottis ‘omega’ shaped.
- Causes obstruction
How does laryngomalacia present ?
- Intermittent inspiratory stridor worse when : upset, lying on back or URTI. Worse on feeding in the exam q.
- Peaks at 6 mnths
- Usually self resolves
What is Primary ciliary dyskinesia? (PCD)
- Autosommal recessive condition causing dysfunction in motile cilia
Who does PCD effect ?
- Communities where consanguinity is present
what is Kartagner’s triad often seen in PCD?
- Paranasal sinusitis
- Bronchiectasis
- Situs Inversus
What kind of hypersensitivity reaction is asthma/other atopic conditions ?
- Type 1
- IgE mediated
Explain the pathophysiology behind asthma
- Environmental trigger
- Smooth muscle is hypersensitive = bronchospasm and constriction
- Increased mucus secretion – Causes airway obstruction
Give the common signs and symptoms of asthma (4)
- Episodic symptoms with intermittent exacerbations
- Diurnal variability, typically worse at night and early morning
- Dry cough with wheeze and shortness of breath
- Bilateral widespread “polyphonic” wheeze
Give 6 common triggers of asthma
- Dust
- Animals
- Cold air
- Exercise
- Smoke
- Food allergens
How is chronic asthma managed in an under 5 ?
- Short-acting beta-2 agonist inhaler (e.g. salbutamol) as required.
- Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
- Add the other option from step 2.
- Refer to a specialist.
How is chronic asthma managed in a 5-12 year old child ?
- Salbutamol
- Add a regular low dose corticosteroid inhaler
- Add a long-acting beta-2 agonist inhaler (e.g. salmeterol).
- Titrate up the corticosteroid inhaler to a medium dose.
-Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast) or oral theophylline - Increase the dose of the inhaled corticosteroid to a high dose.
How is chronic asthma managed in a child over 12?
- Salbutamol
- Add low dose ICS
- Add a long-acting beta-2 agonist inhaler (e.g. salmeterol).
- Titrate up the ICS to a medium dose.
- Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium).
- Titrate the inhaled corticosteroid up to a high dose.
- Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol).
What is the step up of bronchodilators
- Inhaled or nebulised salbutamol
- Inhaled or nebulised ipratropium bromide
- IV mag sulph
- IV aminophylline
How is a mild asthma attack managed ?
- Salbutamol inhalers via spacer
How is a moderate to severe asthma attack managed ?
- Salbutamol via spacer
- Nebulised salbutamol / ipratropium bromide
- Oral pred
- IV hydrocortisone
- IV mag sulph
- IV salbutamol
- IV aminophylline
what is pneumonia and what is seen on a chest X-ray ?
- Infection of the lung tissue
- Consolidation due to pus in the lungs
Give 2 symptoms of pneumonia
- High fever (>38.5)
- Cough : wet and productive
Give 3 characteristic chest signs of pneumonia
- Bronchial breath sounds
- Focal coarse crackles
- Dullness to percussion
Give the most common bacterial and viral cause of pneumonia
- Bacterial : strep pneumonia
- Viral : RSV
How is pneumonia managed ? (dosage in child >11)
- Amoxacillin (500mg 3x daily)
- Add macrolide if atypical
What was the most common cause of epiglottitis prior to vaccination programmes ?
- Haemophilus influenza type B
How does epiglottitis present ?
- Severe sore throat
- Inspiratory stridor
- Drooling and protruding tongue
- Tripod position
- High fever
- Difficult and painful swallow
- Muffled voice
How is epiglottitis managed ?
- SECURE AIRWAY
- IV antibiotics
- Steroids if necessary.
What is cystic fibrosis ?
-Autosomal recessive condition affecting the mucus glands, most commonly caused by Delta-F508 mutation of CFTR gene on chromosome 7
How is CF diagnosed ?
- Newborn bloodspot test
- Sweat test : gold standard
What is an early sign of CF
- Meconium ileus
Give 6 symptoms of CF
- Chronic cough
- Thick sputum production
- Recurrent resp tract infections
- Steatorrhoea
- Abdo pain and bloating
- Salty taste to child
- Failure to thrive
Give 5 signs of CF
- Low weight or height on growth charts
- Nasal polyps
- Finger clubbing
- Crackles and wheeze on auscultation
- Abdo distention
What is the gold standard test for CF?
- Sweat test
What chloride concentration is diagnostic for CF on a sweat test
> 60mmol/L
What are 2 common microbial colonisers in people with CF?
- Staph aureus : long term prophylactic flucloxacillin taken
- Psuedomonas aeruginosa : treated with nebulised tobramycin
what is a common finding in CF in a male
Bilateral absence of vas deferens
How is epiglottitis confirmed ?
- Direct visualisation (only by senior/airway trained staff).
- X ray : lateral = ‘thumbprint sign’
Explain the basics of paediatric life support
- Unresponsive?
- Shout for help
- Open airway
- Look, listen, feel for breathing
- Give 5 rescue breaths
- Check for signs of circulation
infants use brachial or femoral pulse, children use femoral pulse - 15 chest compressions:2 rescue breaths
Explain the key features of chest compressions in children
- Chest compressions should be 100-120/min for both infants and children
depth - Depress the lower half of the sternum by at least one-third of the anterior–posterior dimension of the chest
What 3 features suggest a diagnosis of viral induced wheeze over asthma ?
- Presenting <3 yrs
- NO atopic history
- Only occurs during vital infections
What is CLDP ?
- Premature babies (usually <28 wks gestation) suffer with respiratory distress syndrome and require O2 therapy or intubation and ventilation
Diet recommended in pts with CF
- High calories, high fat and pancreatic enzyme supplementation for every meal
